Evidence-Based Practice in Vestibular Rehabilitation

Evidence Based Practice in Evidence Based Practice in Vestibular Rehabilitation: An Vestibular Rehabilitation: An Occupation-based PerspectiveOccupation-based Perspective

Brenda S. Howard MHS OTRBalance Point IndianapolisAnd University of Indianapolis, DHS ProgramOctober 26, 2013

How is Vestibular Rehabilitation How is Vestibular Rehabilitation Occupation-Based?Occupation-Based?

• Vestibular function underlies all human activity

• Vestibular impairment impacts all occupations

• Occupational Therapy Perspective• Remediate vestibular function• Compensate for safety• Environmental modification

How is Vestibular Rehabilitation How is Vestibular Rehabilitation Evidence-Based?Evidence-Based?

• Evaluation based in neurology & evidence

• Treatment tools based in evidence• Foundation of evidence allows for

creativity in practice• See reference list

Learning ObjectivesLearning Objectives Gain knowledge of vestibular rehab and

evidence Identify vertigo, central vs. peripheral Three tools for evidence-based

assessment and treatment When to refer Spark interest in further education

What do patients complain of when What do patients complain of when they have a vestibular impairment?they have a vestibular impairment?

Vertigo a sense of movement where there is no

movement; an illusion of movement


Dizziness a combination of vertigo, lightheadedness, and

imbalance


Vision Hearing Nausea


Cognition Balance, Coordination Emotions

Central ConnectionsCentral Connections

• Vestibulo-ocular reflex• Vestibulo-spinal reflex• Vestibulo-collic reflex• Autonomic connections• Limbic connections

What can go wrong? Peripheral What can go wrong? Peripheral causes of vertigocauses of vertigo

Unilateral Vestibular Hypofunction

◦ Peripheral Vestibular Asymmetry ◦ Labyrinthitis◦ Vestibular Neuronitis◦ Vestibular Infarct◦ Vestibular Schwannoma/Acoustic

Neuroma(Herdman, 2007; Herdman & Clendaniel, 2007)

Peripheral Vertigo History and Peripheral Vertigo History and SymptomsSymptoms

Sudden onset (illness, trauma, or unknown)

Constant dizziness, provoked by motion (especially head and body turns)

(Herdman, 2007; Herdman & Clendaniel, 2007)


Discomfort with watching movement or patterns

Mild-Moderate Imbalance



Horizontal unidirectional gaze-evoked nystagmus

http://www.youtube.com/watch?v=YntJiBCz3pA


Bilateral Vestibular Hypofunction Bilateral Vestibular Hypofunction

Not dizzy Off balance No balance in the dark Oscillopsia (“things bounce visually”)

Bilateral Vestibular Hypofunction Bilateral Vestibular Hypofunction

Dynamic Visual Acuity loss of greater than 6 lines

Immediate fall Romberg eyes closed on compliant surface

Causes: Chemotherapy, ototoxic antibiotics, autoimmune

BPPV (Benign Paroxysmal BPPV (Benign Paroxysmal Positional Vertigo)Positional Vertigo) Etiology:

Otoliths in semicircular canal Cupula deflects more than usual

(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)

BPPVBPPV Posterior canal: 95% of cases


BPPV SymptomsBPPV Symptoms Dizziness with position changes Lying flat, rolling over, sit up, stand up, bend

over, look up “Top Shelf or “Dentist Office” vertigo Strong spinning for less than one minute May have “leftover” symptoms for hours

Seniors may describe symptoms differently; rocking, tilting, passing out


BPPV is Designated by:BPPV is Designated by:Canal

◦Right or left◦Anterior (Superior)◦Posterior ◦Horizontal

Otolith Position◦Canalithiasis◦Cupulolithiasis

BPPVBPPVDiagnosed with Dix Hallpike maneuver

BPPV Nystagmus:BPPV Nystagmus:

http://www.youtube.com/watch?v=gyvSmTlGu2k

BPPV – Canalith RepositioningBPPV – Canalith RepositioningEpley Maneuver for Posterior Canal BPPV

canalithiasis

What can go wrong? Central What can go wrong? Central Causes of VertigoCauses of Vertigo

• Migraine Associated Vertigo (MAV), Vestibular Migraine

• Post-Concussive Disorder• CVA (cerebellar, pontine)


Vestibular MigraineVestibular Migraine

• May or may not have headache• May have vertigo without migraine• Headache may be low grade but

persistent• A history of migraines (or persistent

headaches)



• Symptoms similar to a unilateral vestibular loss but with no objective findings on VNG

• Motion, light, and sound sensitive



• May be episodic • Or may “wax and wane”• Typically responds better to balance

and gentle habituation exercises


Post Concussive DisorderPost Concussive DisorderCentral AND Peripheral

Concussion Labyrinth trauma BPPV

Cognition Headache – post-concussive migrainesImbalanceMotion sensitive, visually sensitive


CVA – Cerebellar, PontineCVA – Cerebellar, Pontine◦ Diplopia, dysmetria, dysarthria◦ “Constant hum” of vertigo◦ Pursuits/Saccades◦ Subjective visual vertical◦ Direction-changing nystagmus

http://www.youtube.com/watch?v=jeYe-SMMW9k


Diagnostic TestsDiagnostic Tests Medical Tests: MRI, CT, cardiac Audiology Tests:

Audiogram VNG/ENG Rotary Chair Positional Testing including Dix Hallpike VEMP Computerized Dynamic Posturography (CDP)

Vestibular Therapy EvaluationVestibular Therapy EvaluationHistory

Detailed description of symptoms Past Medical History, Medications Occupational Profile – the “so what” Questionnaires

◦Dizziness Handicap Inventory (Jacobson, et al., 1990)

◦ABC Scale (Whitney, et al, 1999)

Oculomotor ExamOculomotor ExamPursuitsSaccadesGaze Evoked NystagmusSlow Head RotationEye-Head to PeripheryDynamic Visual Acuity (DVA) – using

logMAR chart (Herdman et al., 2003)

Gaze-Evoked NystagmusGaze-Evoked Nystagmushttp://www.youtube.com/watch?

v=mghGeKkNBzQ

Dynamic Visual Acuity and x1Dynamic Visual Acuity and x1http://www.youtube.com/watch?v=8eWKMO7RNak

Practice!Practice!Dynamic Visual AcuityVestibular Adaptation Exercises – x1 Gaze

Stabilization

◦What are some ways you can grade this exercise?

◦How can you add a functional component?

BPPV Evaluation and TreatmentBPPV Evaluation and TreatmentDix Hallpike and Canalith Repositioning

(Epley) ManeuverDix Hallpike:

http://www.youtube.com/watch?v=7pDOaFKrTbU

Epley: http://www.youtube.com/watch?v=ZqokxZRbJfw

PRACTICE!PRACTICE!

Dix Hallpike and Canalith Repositioning Maneuver

American Academy of Neurology American Academy of Neurology BPPV Assessment and Treatment BPPV Assessment and Treatment (full video)(full video)http://www.youtube.com/watch?v=hq-

IQWSrAtM

HabituationHabituationTest: Motion Sensitivity Quotient (Test)

(Shepherd & Telian, 1995; Akin & Davenport, 2003)

Habituation Exercises◦Otolith ◦Semicircular Canals◦Functional Movement: Progressive Sequences◦Brandt Daroff: NOT a habituation exercise(Whitney & Sparto, 2011; Clendaniel, 2010; Cohen, et al., 2006;

Cohen, et al., 1995; Cronin, 2013)

Habituation, continuedHabituation, continuedExercises:

◦Head horizontal, vertical◦Forward bend in straight plane, diagonal◦Wall rolling, ball-to-wall◦Add a functional task!

Vestibular Habituation Vs. Vestibular Habituation Vs. Adaptation – when to use?Adaptation – when to use?

Use adaptation for impaired VOR (DVA)Use habituation for motion sensitivity

You can use both, but be cautious to not overload the vestibular system

BalanceBalancemCTSIB (Modified Clinical Test of

Sensory Integration and Balance) (Shumway-Cook & Horak, 1986; Cohen, et al., 1993)

Dynamic balance◦Dynamic Gait Index (DGI) (Whitney, et al., 2000)

◦Functional Gait Assessment (FGA) (Wrisley, et al., 2010)

BalanceBalanceDemonstration and Practice!

◦Come up with one adaptation of this test that could be used for treatment

◦Come up with one functional activity to be used for balance treatment

Evidence-Based Treatment Evidence-Based Treatment Techniques - summaryTechniques - summary

Canalith Repositioning (Epley) Maneuver Vestibular Adaptation Exercise (x1) Habituation Exercises Static and Dynamic Balance Exercises

Evidence-Based Treatment Evidence-Based Treatment Techniques - summaryTechniques - summary

Compensatory techniques, sensory calming techniques (relaxation, deep breathing, visual targeting)

Functional activities, of course! - always link treatment to the patient's occupation-based goals

Patient Education ResourcesPatient Education Resources

Vestibular Disorders Association◦www.vestibular.org

Dr. Timothy Hain MD – “The Dizzy Doctor”◦http://www.dizziness-and-balance.com/

index.html

◦http://dizzy-doctor.com/index.phpVestibular Seminars

◦http://www.vestibularseminars.com/home.html

Case Study ExamplesCase Study Examples

What is one thing you would like to test?

If positive, what treatment would you select?

What referrals might you make?

A Word about Fall PreventionA Word about Fall Prevention

Multiple factors:◦Cognitive◦Environmental◦Strength, Endurance, Balance◦Peripheral Neuropathy◦Orthopedic Deficits◦Neurologic Deficits◦Vertigo◦Behavioral

All must be addressed!(AGS/BGS, 2010)

A Word about Non-Vestibular A Word about Non-Vestibular Causes of VertigoCauses of Vertigo

CardiacVertebrobasilar insufficiencyOrthostatic hypotensionLow blood pressureLow blood sugar


A Word about Non-Vestibular A Word about Non-Vestibular Causes of VertigoCauses of Vertigo

Autoimmune disordersOther central disorders (MS, PD)Psychogenic – anxiety, depressionMedicationsCervicogenic(Herdman, 2007; Herdman & Clendaniel, 2007)

A Word About PrecautionsA Word About PrecautionsNeck ROM, painBack painFall RiskCirculatory issues

◦Vertebrobasilar Artery CompressionAutonomic reactionsNausea, vomitingSeizuresCoexisting diagnoses

When to ReferWhen to Refer

Refer to MD, ENT, Neurologist for diagnosis

Refer to audiologist for VNG, audiogram for suspected ear pathology

Refer to vestibular rehabilitation specialist if patient does not respond to treatment in 2-3 weeks OR if you are unsure what to do based on what you know

A Word about LogisticsA Word about LogisticsAOTA Position Paper (Cohen, et al., 2006)Indiana License (IPLA, 2011)Billing CPT codes:

◦Initial: 97003◦Timed treatment codes: 97112 (neuromuscular

re-education), 97110 (therapeutic exercise), 97530 (therapeutic activity).

Recommended CoursesRecommended Courses

Education Resources: Richard Clendaniel DPT, Gaye Cronin OTR

Jeff Walters DPT - http://www.vestibularseminars.com/

Sue Whitney PTJanet Helminski PT, Dr. Timothy Hain MDAPTA/Emory University Certificate Course

(Susan Herdman PT)Dr. Richard Gans PhD

http://dizzy.com/education_without_boundaries.htm

(See Cohen, et al., 2011 for educational guidelines)

SummarySummary

Evidence-basedOccupation-based

Post-testCourse Evaluation

THANK-YOU FOR ATTENDING!THANK-YOU FOR ATTENDING!

http://www.youtube.com/watch?v=rbwmfEXu75s

ReferencesReferences Akin, F., & Davenport, M. (2003). Validity and reliability of the Motion Sensitivity

Test. Journal of Rehabilitation Research and Development, 40(5), 415-422. American Geriatrics Society & British Geriatrics Society (AGS/BGS). (2010).

Clinical practice guideline: Prevention of falls in older persons. Journal of the American Geriatrics Society (special article). Retrieved May 17, 2013 from http://www.americangeriatrics.org/health_care_professionals/clinical_practice/ clinical_guidelines_recommendations/2010/

Clendaniel, R. (2010). The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: a preliminary results [sic] [Abstract]. Journal of Neurologic Physical Therapy, 34(2), 111-116.

Cohen, H. (2011). Assessment of functional outcomes in patients with vestibular disorders after rehabilitation. Neurorehabilitation, 29, 173-178.

Cohen, H., Blatchly, C., & L., Laurie. (1993). A study of the Clinical Test of Sensory Interaction and Balance. Physical Therapy Journal, 73, 346-351.

Cohen, H., Burkhardt, A., Cronin, G., & McGuire, M. (2006). Specialized knowledge and skills in adult vestibular rehabilitation for occupational therapy practice. American Journal of Occupational Therapy, 60(6), 669-678.

Cohen, H., Kane-Wineland, M., Miller, V., & Hatfield, C. (1995). Occupation and visual/vestibular interaction in vestibular rehabilitation. Otolaryngology-Head and Neck Surgery, 112(4), 526-532.

Cohen, H., Gottshall, K., Graziano, M., Malmstrom, E., Sharpe, M., & Whitney, S. (2011). International guidelines for education in vestibular rehabilitation therapy. Journal of Vestibular Research, 21, 243-250.

Cronin, G. & Steenerson, R. (2011). Disequilibrium of aging: Response to a 3-month program of vestibular therapy. Physical & Occupational Therapy in Geriatrics, 29(2), 148-155

Cronin, G. (June 14-15, 2013). Vestibular Rehabilitation: Treatment Intensive (course manual). Philadelphia, PA: Education Resources, Inc.

Epley, J. (1992). The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery, 107(3), 399-404.

Epley, J. (1995). Positional vertigo related to semicircular canalithiasis. Otolaryngology-Head and Neck Surgery,112(1), 154-161.

Hain, T. Dizziness, imbalance, and hearing disorders. Retrieved on June 30, 2013 from http://www.dizziness-and-balance.com/disorders/index.html

Haven, L. (2011, Summer/Fall). VEDA produces benchmark study to help reduce suffering. On the Level: Quarterly Newsletter of the Vestibular Disorders Association, 28(3-4), 1-8.

Helminski, J., Zee, D., Janssen, I., & Hain, T. (2010). Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: A systematic review. Physical Therapy Journal, 90(5), 663-678.

Herdman, S.(Ed.). (2007). Vestibular Rehabilitation (3rd ed.). Philadelphia: FA Davis Co.

Herdman, S. & Clendaniel, R. (March 13-17, 2007). Vestibular Rehabilitation: A competency-based course (course manual). Atlanta, Georgia: Department of Rehabilitation Medicine, Emory University School of Medicine and American Physical Therapy Association.

Herdman, S., Schubert, M., Das, V., & Tusa, R. (2003). Recovery of dynamic visual acuity in unilateral vestibular hypofunction. Archives of Otolaryngology-Head and Neck Surgery, 129, 819-824.

Hernandez, D. & Rose, D. (2008). Predicting which older adults will or will not fall using the Fullerton Advanced Balance scale. Archives of Physical Medicine and Rehabilitation, 89(12), 2309-2315.

Indiana Professional Licensing Agency Occupational Therapy Committee (IPLA). (2011). Occupational Therapy Committee: Laws and Regulations: A compilation of the Indiana Code and Indiana Administrative Code. Retrieved from http://www.in.gov/pla/files/OTC.2011_EDITION.pdf

Jacobson, G., Newman C., Hunter, L., et al. (1990). The development of the dizziness handicap inventory. Archives of Otolaryntology-Head and Neck Surgery, 116, 424-427.

Shepherd, N. & Telian, S. (1995). Programmatic vestibular rehabilitation. Otolaryngology-Head and Neck Surgery, 112, 173.

Shumway-Cook, A., & Horak, F. (1986). Assessing the influence of sensory interaction of balance: suggestion from the field. Physical Therapy Journal, 66, 1548-1550.

Vestibular Disorders Association (VEDA). Living with a vestibular disorder. Retrieved on June 30, 2013 from http://vestibular.org/living-vestibular-disorder

Whitney, S., Hudak, M., & Marchetti, G. (1999). The Activities-specific Balance Confidence scale and the Dizziness Handicap Inventory: A comparison. Journal of Vestibular Research,9, 253-259.

Whitney, S., Hudak, M., & Marchetti, G. (2000). The dynamic gait index relates to self-reported fall history in indifivuals with vestibular dysfunction. Journal of Vestibular Research, 80, 896-903.

Whitney, S. & Sparto, P. (2011). Principles of vestibular physical therapy rehabilitation. Neurorehabilitation, 29, 157-166.

Wrisley, D. & Kumar, N. (2010). Functional gait assessment: Concurrent, discriminative, and predictive validity in community-dwelling older adults. Physical Therapy Journal, 90, 761-773.

Evidence-Based Practice in Vestibular Rehabilitation

Health & Medicine

Transcript of Evidence-Based Practice in Vestibular Rehabilitation